An Ontario tribunal has backed Intact Insurance's right to challenge whether an accident occurred - four years after it began paying benefits.
The Licence Appeal Tribunal dismissed a claimant's bid for statutory accident benefits after finding he had not proven he was involved in an accident as defined under Ontario's auto insurance regime.
The dispute traces back to July 29, 2021, when the claimant, riding a bicycle fitted with an electric motor, was admitted to North York General Hospital at 7:21 p.m. He told hospital staff his front tire went into a pothole, flipping the bike and injuring him.
But his application for accident benefits, dated August 17, 2021, told a different story - that he had been struck by a vehicle at Highway 7 and Highway 404 at 3:00 p.m. No police report confirmed a vehicle was involved. Even so, the insurer opened a claim and paid benefits, totalling $2,417.76 in medical and rehabilitation costs, according to a Statement of Benefits dated December 12, 2024.
The insurer's approach shifted after the claimant sought a catastrophic impairment determination in July 2023. Following insurer examinations and an examination under oath in March 2025, the insurer denied coverage on June 9, 2025, arguing the claimant had failed to prove that the use or operation of an automobile directly caused his injuries.
The claimant countered that the insurer was estopped from raising the issue, having accepted his claim and paid benefits for four years before questioning whether an accident occurred at all. He argued the insurer had a duty to investigate and flag a potential denial while evidence was fresh.
The tribunal was not persuaded. Citing the Divisional Court's decision in Davis v. Aviva, where an insurer raised the same preliminary issue years into paying a claim, the adjudicator found no bar to the insurer challenging coverage well after payments began. Estoppel, she found, did not apply, and she was bound by Davis to allow the insurer to raise the issue years after accepting the claim.
On the facts, the claimant's competing accounts proved decisive. He later explained that he had lied to hospital staff to protect an unidentified driver who drove him home, and said he had consistently told assessors he was struck by a car. At his examination under oath, he described his handlebars striking the front of a vehicle in a crosswalk.
The adjudicator preferred the contemporaneous hospital records. She noted the records created immediately after the incident made no mention of a vehicle, and that there were no witnesses, no vehicle details, and no corroborating evidence. "The facts are contentious in this case," she wrote, pointing to inconsistencies in the claimant's statements.
The claimant, she concluded, had not met the purpose test, and even if he had, the causation test would also fail. The application was dismissed.
